Adenoid Hypertrophy Ct Scan

Fig. 2.14 A harmless-looking polyp medial to the middle turbinate and an infective-looking polyp at the origin of the turbinate—at histology an adenocarcinoma.

Turbinate Hypertrophy

Fig. 2.15 Children below the age of 6 years average eight upper respiratory tract infections a year. Clear periods between infections will help distinguish upper respiratory tract infections from other causes of rhinosinusitis.

Fig. 2.15 Children below the age of 6 years average eight upper respiratory tract infections a year. Clear periods between infections will help distinguish upper respiratory tract infections from other causes of rhinosinusitis.

of colds decreases in frequency by the age of 8-10 years (Fig.2.16a-d).

The main treatment strategy should be conservative and not surgical. Explain to anxious parents that simple, noninvasive measures such as teaching nose-blowing, the use of saline sprays, or a trial of allergen avoidance and age-appropriate topical nasal anti-inflammatory sprays should be tried before surgery is contemplated. Because such infections are so common, antibiotics given for chronic nasal discharge often have short-lived effects.

Rhinosinusitis in children is not a surgical disease; "watchful waiting" is advised (Fig. 2.17). Any treatment should have safety as its first priority, as the problem usually resolves with time without intervention. It is likely that growth and maturation of the immunological response to pathogens play a major role in resolution of the disease (Jones, 1999 a; Howe and Jones, 2004).

There are few exceptions to this principle: nasal polyps (indicating possible cystic fibrosis (Fig. 2.18a, b)) and periorbital cellulitis (Fig. 2.19a, b). In periorbi tal cellulitis, an assessment of vision, parenteral antibiotics, and topical decongestants should be given. If there is concern about the possibility of a subperiosteal abscess, a CT scan should be obtained. Central signs, being unable to accurately assess vision, gross proptosis, ophthalmoplegia, deteriorating visual acuity or color vision, bilateral edema, no improvement or deterioration at 24 hours or a swinging pyrexia that does not resolve within 36 hours are all indications for a CT scan. If a subperiosteal abscess is found on CT, drainage of any pus is indicated.

■ Who Not to Select for Surgery

Never coerce any patient into having surgery for rhinosinusitis (Fig.2.20a, b). The patient has to want to proceed, knowing what can realistically be achieved and what risks are involved. At the same time, do not be forced into operating by a patient who has unrealistic expectations and whose symptoms do not correlate with clinical findings. Beware that patients often ex-

Down Syndrome Adenoid Hypertrophy

Fig. 2.16 a Adenoid hypertrophy: this usually involutes without intervention by the age of 8 years. b, c, d Lateral soft-

Fig. 2.16 a Adenoid hypertrophy: this usually involutes without intervention by the age of 8 years. b, c, d Lateral soft-

tissue plain radiographs, found by chance, of the same child over several years showing natural involution of the adenoid.

Fig. 2.17 A CT scan done in an asymptomatic child having the > investigation for an unrelated reason, showing coincidental mucosal changes—a common finding.

Adenoid Hypertrophy

Fig. 2.18 a Middle meatal polyps and a smear of mucopus in a child that is consistent with cystic fibrosis. b Corresponding coronal CT scan.

Adenoid Hypertrophy Scan From Periorbital Abscess

Fig. 2.19 a Clinical and b CT view showing a right periorbital abscess (arrow).

Fig. 2.19 a Clinical and b CT view showing a right periorbital abscess (arrow).

b a pect that all their symptoms will be cured by surgery— even those symptoms that they have not mentioned. Be sure to clarify those symptoms that may be helped and those that are unlikely to improve. Patients occasionally have sizable nasal polyps without any symptoms. Before operating, you would be well advised to manage these patients medically, delaying surgery until they develop symptoms.

■ Patient Expectations

Finally, we need to make sure that patients understand that it is usually not possible to cure them of their polyps forever or to eradicate all their symptoms. We explain to our patients that their symptoms are like a person trying to get from the ground floor of a skyscraper to the top floor in order get a good view. On the a

Bilateral Nasal Specific

Fig. 2.20 a A patient with bilateral nasal polyps visible at endoscopy, but who is asymptomatic. b A patient with allergic rhinitis whose symptoms are unlikely to be helped by surgery.

Fig. 2.20 a A patient with bilateral nasal polyps visible at endoscopy, but who is asymptomatic. b A patient with allergic rhinitis whose symptoms are unlikely to be helped by surgery.

b a ground floor, they feel blocked, with a poor sense of smell and postnasal mucus. Medical treatment can get them up a few flights of stairs, and oral steroids may get them near the top in a lift, but the lift often comes down again. Surgery together with medical treatment will help them to get a better view for a longer period, but it will not necessarily get them to the top floor (Fig. 2.21).

While symptoms of obstruction are often greatly improved, those of a sensation of postnasal discharge may well not be altered. Hyposmia is often improved if the mucosa in the olfactory cleft is preserved and medical treatment is continued.

Only a minority of patients with nasal polyps have symptoms of pain or pressure. If their symptoms are exacerbated by a respiratory tract infection or a change in barometric pressure, they are more likely to benefit from surgery. Be cautious if their pain or pressure does not have these features, as it may be incidental and not helped by surgery.

Turbinates Surgery
Fig. 2.21 Skyscraper analogy. The surgeon can use this illustration to explain symptom goals to patients.
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